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Aug 09 Safety Meeting. Larry Brockshus. Overview. Aug Sentinel SA Lightning CAP June Aircraft Mishaps 2009 Aircraft incidents 101 Critical Days of Summer MN Wing Grounding. Loss of Situational Awareness Due to Ineffective Scan.

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Aug 09 Safety Meeting

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aug 09 safety meeting

Aug 09 Safety Meeting

Larry Brockshus

  • Aug Sentinel
    • SA
    • Lightning
    • CAP June Aircraft Mishaps
  • 2009 Aircraft incidents
  • 101 Critical Days of Summer
  • MN Wing Grounding
loss of situational awareness due to ineffective scan
Loss of Situational Awareness Due to Ineffective Scan
  • Several CAP mishaps due to a loss of Situational Awareness (SA).  
    • Landing our aircraft fast resulting in damaged firewalls
    • Slow resulting in hard landings.
    • Vehicles are backing into objects/other vehicles.
    • Members stepping into holes, tripping over curbs,
    • Not keeping ourselves hydrated, cutting ourselves with knives etc.
lsa scan
  • Inappropriate/ineffective scan greatly increases loss of situation awareness (hereafter, LSA)
  • Breakdown in scan is one of the leading contributors to mishaps/LSA
  • ‘Good’ scan requires training and practice.
what is situation awareness sa
What is Situation Awareness (SA)?
  • SA: An attention-based phenomenon reflecting the state of a pilot's awareness based on:
    • The perception & cognition of information related to the spatial world in and about the aircraft and the hazards in that environment.
    • The systems (especially those that are automated) onboard the aircraft itself.
    • The nature of the tasks at hand.
principles of scan and situational awareness
Principles of scan and situational awareness
  • Tactical visual scan: a sequential monitoring task where a pilot combines the data gained from each separate outside and cockpit instrument fixation into full situation awareness.
  • Pilots quickly create scan and fixation patterns for each different required maneuver (i.e., transition through heading and altitude, takeoff, landing, etc.)
  • Scan characteristics (pattern, frequency and duration of fixations):
    • determined by the intrinsic nature,
    • complexity,
  • Importance of the information provided Scan patterns and fixations may reflect a strategy based on what a pilot needs to know, or thinks he/she needs to know, at a given time
what causes scan to breakdown
What Causes scan to ‘Breakdown’?
  • Distractions,
  • Workload,
  • Automation, display design - “Glass Cockpit”,
  • Complacency,
  • Inadequate/inaccurate mental model
  • Lack of/poor scan training
applies to all cap members
Applies to all CAP members
  • There is basically no difference in the scan vs. situational awareness whether driving a CAP vehicle or cadets and seniors performing activities such as encampments, PT or ES.
  • Scan for the hazards (ORM) and use this information to keep yourself and others safe
lightning safety
Lightning Safety
  • The National Weather Service lightning safety website (
lightning safety1
Lightning Safety
  • The National Weather Service (NWS) reports a 30-year average of 58 deaths per year in the United States
  • At a wing encampment this year, lightning struck a communications antenna mounted on a trailer
    • Damaged several pieces of equipment.
    • Cadet was using a laptop experienced an electrical shock.
    • Neither the antenna nor the trailer was grounded
tips to avoid injury during thunderstorms
Tips to avoid injury during thunderstorms:

• Thunderstorms happen year round.

• Lightning can strike as far 10 miles from the area of rain

• Remember: If you can hear thunder, you are close enough to be struck by lightning

there is little you can do to substantially reduce your risk if you are outside in a thunderstorm
There is little you can do to substantially reduce your risk if you are outside in a thunderstorm

• Move to a safe shelter: fully enclosed, plumbing and/or wiring.

  • Unsafe buildings: Car ports, open garages, covered patios, picnic shelters, beach pavilions, golf shelters, tents of any kinds, baseball dugouts, sheds and greenhouses.

• Stay away from showers, sinks, hot tubs, and electronic equipment such as TVs, radios, corded telephones and computers.

• If you are unable to take shelter in a safe building, seek a safe vehicle. One that is fully enclosed, metal topped such as a hard topped car, minivan, bus, truck, etc.

  • Unsafe vehicles include convertibles, golf carts, riding mowers, open cab construction equipment and boats without cabins.
  • Do NOT leave the vehicle during a thunderstorm.
if away from building vehicle
If away from building/vehicle
  • Avoid open fields, the top of a hill or a ridge top.
  • Keep away from tall, isolated trees or other tall objects.
  • Set up camp in a valley, ravine or other low area (consider possible flash flooding).
  • Stay away from water, wet items such as ropes, and metal objects
  • The vast majority of lightning injuries and deaths on boats occur on small boats with no cabin.
    • If you are caught in a thunderstorm on a small boat, drop anchor and get as low as possible.
summary of form 78 aircraft accidents and incidents for june 2009
Summary of Form 78 Aircraft Accidents and Incidents for June 2009
  • Aircraft wingtip struck hangar while taxiing
  • Tow hook damaged during glider tow operation
  • Dent found on leading edge of right wing*
  • Aircraft wing tip grazed a light pole while taxiing
  • Tail tie down ring sheared off during soft field takeoff
  • Nose wheel tire flat on landing rollout
  • Found small dent and paint missing on wing tip*
  • Aircraft hit runway light while taxiing in grass to tie down area
mn wing aircraft incidents
MN Wing Aircraft Incidents
  • 19 Feb, #1218, Damage on horizontal stab
  • 21 Mar, #1262, Hit tie down ring, Soft Field T.O.
  • 17 Apr, #1303, Hit tie down ring, Student Solo
  • 23 May, #1376, Bent Aileron
  • 30 May, #1390, Scraped rear tail box
  • 18 Jun, #1437, Wing leading edge dent
  • 23 Jun, #1492, Scraped wing tip
  • 23 Jul, #1604, Cadet solo aborted T.O., slid off runway
  • 23 Jul, #1608, Wingtip hit porta-potty
  • 3 incidents of aircraft tail hitting to ground
    • Training
    • Technique
  • 5 incidents had an unknown cause
    • Poor pre/post-flights
    • Integrity?
  • 1 ignored taxi obstacle clearance criteria
  • 1 could have led to catastrophic injury/aircraft damage
  • All were preventable
101 critical days of summer1
101 Critical Days of Summer
  • Memorial Day Weekend through Labor Day Weekend
    • “Critical” because many lose their lives
    • More activities mean more risk
    • More risk means more injuries
    • Safety = Planning with knowledge of the past and making choices that prevent mishaps
    • Some risk is necessary for a meaningful life
    • Must weigh benefits and costs of each risk
vehicle safety
Vehicle Safety
  • As a result of 6,000,000 car accidents in the US each year
    • 3,000,000 will be injured
    • 42,000 will be killed
    • The leading cause of fatal mishaps during this period
  • Contributing factors include: Fatigue, alcohol, drugs, speeding & not using seatbelts
  • Survival plan:
    • Insist on seat belt use
    • Don’t drive impaired
    • Plan your trip
    • Inspect your vehicle
    • Don’t speed (or go too slow)
    • Don’t tailgate
water safety
Water Safety
  • Each year in the US,
    • 3,500 drown
    • 4,500 injured while boating
    • 700 killed while boating
  • PFDs could reduce fatalities 90%
  • Contributing factors include: alcohol, lack of PFDs, horseplay, and underwater obstructions
  • Survival plan:
    • Use a “designated Captain”
    • Don’t overload the boat
    • PFDs on weak swimmers
    • Explore water/feet first
    • Keep throwable PFD nearby
    • Use the engine kill switch
  • Weather Dangers
    • All Thunderstorms are dangerous
    • Lightning kills more people each year than tornadoes
    • Hailstones can fall at speeds in excess of 100 mph
  • Stay inside when storms are approaching
  • Listen for information on Watches and Warnings
  • The goal is FUN this summer!
  • When someone is injured - it stops being fun!
  • Make your own luck by managing risks
  • Have fun by being careful out there!
mn wing grounding
MN Wing Grounding
  • MN Wing must develop program to decrease incidents
  • Col Theis requested inputs from commanders and staff
  • Input from teleconference:
    • Take pictures of aircraft damage
    • Hold safety clinics/add to SAR exercises
    • Develop use robust pre/post checklists
    • Publish form 78/79s
    • Avoid non-value added paperwork
additional input from a highly experienced instructor and safety officer not me
Additional input from a highly experienced instructor and safety officer (not me)
  • Things That do Not Work
    • Posters
    • Slogans
    • Pledges
    • One way communication
    • Blaming the victim
    • Trying to change people, not processes
a management problem
A Management problem
  • Deming – 90% of problems are caused by management
  • John Laubner NTSB- Corporate culture has a very real influence on attitudes and performance…management decisions and actions cause accidents.*
  • J. Lederer- Every accident, no matter how minor is a failure of organization.*
  • Processes not people must change
  • The best example of CAP process change was to switch from tailwheel to tricycle aircraft. The accident rate dropped dramatically.
  • The outstanding safety record of the airlines is due to the establishment of effective processes that cover all aspects of their operation.
  • Management, must demonstrate scrupulous adherence to the rules if a rule based culture is to be established.
the solution one proposal
The solution (One proposal)
  • Management at all levels must demonstrate strict adherence to the rules. e.g. if the compass card is missing, the airplane is grounded on the spot. Publicize this action.
  • A safety conscious culture is established by management demonstrating the desired behavior; is reinforced by peer pressure.
  • Peer pressure is established through frequent personal contact among those affected, e.g. unit pilots meet at least once a month and discuss nothing except details of their flying operation. Everyone knows what everyone else is doing. Every pilot feels that all the other pilots are looking over his shoulder.
  • Publicize all incidents.
  • Review what processes were involved in each incident. Affect changes that should improve these processes. e.g. installation of stops in the St. Paul hangar ; insisting on a static rpm check on takeoff /establishing an abort point.
the solution one proposal1
The solution (One proposal)
  • Appoints squadron maintenance officers. Among his duties should be to determine the action required for each aircraft squawk. He should coordinate repairs or deferral with Wing operations, keeps the unit informed.
  • Return units to flying status upon appointment of a maintenance officer, establishment of a pilot
  • Meet with all squadron commanders, teach that a safe culture begins with managers exhibiting the desired behavior and expecting the same from their subordinates.
  • Teach that process change and that continuous process improvement is as applicable to safety
  • Establish channels for safety improvement at all levels. Make it easy for any one to offer a safety suggestion and insure that they are taken seriously. Follow up.
  • Processes are most often improved by a multitude of small changes initiated from the bottom up. Major changes initiated from the top down are less often effective.